OTA 2012 Posters

Scientific Poster #18 Hip/Femur OTA-2012

A Retrospective Study of a Comprehensive Pain Protocol Using a Continuous Fascia Iliaca Compartment Block

Elizabeth Dulaney-Cripe, MD1; Scott J. Hadaway, DDS, MD2;
Carole Smith, CNS, BC, CCRN2; Brett C. LaFleur, MD1; G. Ryan Rieser, MD1;
Ryan D. Bauman, MD2; Michael J. Prayson, MD1; Richard T. Laughlin, MD1;
1Department of Orthopaedic Surgery, Wright State University, Dayton, Ohio, USA;
2Miami Valley Hospital, Dayton, Ohio, USA

Background/Purpose: Hip fractures account for 350,000 fractures annually, and the projected incidence is expected to exceed 6.3 million by 2050. Multiple strategies have been employed to reduce complications and hospital stay, including pre-emptive pain medications, nerve blocks, and prompt fixation of fractures. The use of one block, a fascia iliaca compartment block (FICB), has been shown to be effective in controlling pain in both hip arthroplasty and hip fracture. The purpose of our study is to evaluate the clinical effects of a continuous fascia iliaca block placed preoperatively in addition to a comprehensive pain protocol as measured by pain score, opioid consumption, delirium status, complications, hospital length of stay, disposition, and mortality.

Methods: All patients at our institution with a hip fracture after May 1, 2011 were given the option of having an FICB for pain control. Our goal is to enroll 200 consecutive patients. As soon as practical, an anesthesiologist placed the block in the emergency department or on the orthopaedic unit. The pain service monitored the block until the morning after surgery for treatment of the fracture. The catheter was removed on either postoperative day 1 or 2, depending on efficacy and pain control. During this time, the standard procedures for patients with hip fractures were implemented including the pre-emptive receipt of Celebrex and Lyrica, unless contraindicated. Documentation of pain scores, incidence of delirium, and medication administration including opioid consumption were performed. Other data collected included demographic data (age, gender, comorbidities), prehospitalization ambulatory status and living situation, length of stay, disposition, documentation of delirium, and any complications reported while an inpatient. The group receiving an FICB was compared to the previous consecutive 200 patients with a hip fracture admitted prior to the initiation of the fascia iliaca protocol. The two groups were compared on pain scores, opioid usage, complications, length of stay, disposition, and mortality.

Results: The FICB group (n = 129) did not differ from the comparison group (n = 200) on age, gender, visual analog pain scores on admission, prehospital ambulation status, and prehospital living situation. There were no differences in comorbidities including dementia, chronic obstructive pulmonary disease, and diabetes. The experimental group had less cardiovascular disease (58.6% vs 86.0%, P <0.001). Pain scores on postoperative day 0 were different, with the control group having a mean pain score of 3.23, and the experimental group having a mean pain score of 2.28 (P <0.001). Also, on postoperative day 1, the comparison’s mean pain score was higher (3.05 vs 2.24 (P <002). On postoperative day 2, the two groups did not differ (comparison group mean = 2.86 and experimental group 2.41, P = 0.10). There were no group differences in the amount of acetaminophen, hydrocodone, oxycodone, or dilaudid used. The comparison group used more morphine (mean =18.6 mg vs 6.2 mg; P <0.001). The two groups did not differ on incidence of delirium, hospital length of stay, complication rate, disposition, and mortality.

Conclusion: Fascia iliaca continuous catheters have the potential to reduce the pain scores associated with hip fractures. The effectiveness of fascia iliaca nerve blocks in hip replacement has been demonstrated in several studies. However, no other studies have examined the effect of a continuous compartment block in a large hip fracture cohort.

• The FDA has not cleared this drug and/or medical device for the use described in this presentation   (i.e., the drug or medical device is being discussed for an “off label” use).  ◆FDA information not available at time of printing. Δ OTA Grant.